Secret Report Exposes Serial Neglect at Hospitals

Patients at hospitals run by Pennine Acute Hospital NHS Trust faced years of negligent treatment, misdiagnoses, poor clinical judgement, apathetic and unqualified staff, short-staffing, and chronic under resourcing. This was the verdict of a report commissioned in early 2016 by the Trust itself and prepared by its Director of Maternity Care. Unfortunately for patients at North Manchester General and Royal Oldham Hospitals the report was then buried and only came to light (after repeated denials from the Trust that it even existed) following an investigation by the Manchester Evening News. Once exposed the report made national headlines.

The failings highlighted in the report make for disturbing and in many cases tragic reading. Among the more appalling examples of negligence identified at the Trust between 2010 and June 2016 (when the report was completed) include:

• A premature baby being left to die alone in a room used to dispose of medical waste
• Another baby who died because of an elementary failure to check its mother’s blood type
• Routine failures to take basic observations and keep basic records
• Lab results left unchecked
• Patient records incorrectly, incompletely, or only tardily filled out
• Lack of effective performance monitoring of the Trust’s historically high numbers of agency/locum staff
• Newborn babies’ heart rates not being monitored properly, leading to serious and lifelong health problems (including brain damage) which would otherwise have been preventable
• A woman misdiagnosed as mentally ill when she was actually suffering from a cerebral haemorrhage, and who was subsequently allowed to die of hypoxia over the course of several days
• A woman who was left with a permanent colostomy because her treatable faecal peritonitis was missed by surgeons on three separate occasions over the course of 24 hours

The report identified several root causes of the problems, including an overarching “embedded culture of not responding to the needs of vulnerable women.” Habitual short-staffing was another issue with an especially negative impact on maternity care: “The effect of poor staffing numbers in clinics has meant women have fragmented care, suffered long waits and not had appropriate management.” The report goes on to describe long-standing “poor decision-making” by maternity staff resulting in “significant harm to women and real issues relating to the management of women in labour” which in turn led to “high levels of harm for babies in particular.” Over reliance on locums (one third of total staff) likewise translated into low levels of doctors and nurses with appropriate skills and experience.

The report found that between 2010 and 2015 the Trust paid out over £50million in compensation claims, more than any other NHS Trust in England. Half of this amount was maternity-related. In 2012 the Clinical Negligence Schemes Trust (a division of the NHSLA) was so alarmed by the level of compensation payouts it warned the Trust to clean up its act. In 2014 meanwhile the Trust was subject to an external investigation because of the unusually high level of maternity deaths. The report makes it clear that very little changed. The results of warnings and investigations were routinely ignored. Even at the time the report was completed in June 2016 there had been no fewer than 12 “serious” maternity incidents since April 2016 alone, including the death of a mother, the death of two babies, and three still-births.

In mid-2016 the Manchester Evening News (MEN) received a tip-off about the existence of the report (which had hitherto been kept secret) from a whistleblower and began its own investigation. As late as August 2016 the Trust’s official position was that the report did not exist. It was eventually exposed following growing local concern and persistent questions and requests from the MEN, culminating in an official Freedom of Information Request.

Following exposure of the report all families involved in serious incidents have been invited to meet with the Trust’s head of midwifery. Maternity services are now being overseen by another Trust (Central Manchester NHS Foundation Trust) and a new management team has been put in place on secondment from Salford Royal Hospital Trust. No more high-risk pregnancies are being sent to Manchester General. Trust bosses say that they are now working full-time on improving services and recruiting more and better-qualified staff. It is to be expected that many more compensation claims will follow however.

Freeths LLP provides a comprehensive clinical negligence service with free initial advice. If anyone has any queries flowing from these events please contact Phil McGough at our Nottingham office for further information.

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